STEADFAST INSURANCE COMPANY SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY INSURANCE APPLICATION

Transcription

1 NOTICE: This is an application for claims made and reported insurance with Claim Expenses included within the limits of liability. Such insurance, if accepted by the Company, applies only to those Claims first made against the Insured and reported in writing to the Company while the policy is in force and may additionally limit coverage applicable to negligent acts committed prior to the inception of the Policy Period. A. Please answer all the questions. B. If a question is not applicable, state N/A. Attach additional information as necessary. C. The application must be signed and dated by an authorized officer, partner or principal of the Applicant. PLEASE ATTACH THE FOLLOWING AND (X) THE APPROPRIATE BOX: Attached N/A Brochures, advertisements or other descriptive literature about the Applicant, its subsidiaries, operations and services. Copies of standard contracts and engagement/proposal letter used with clients. Sample reports given to clients. Biographical sketches of principals, officers and professional staff. Copy of the Internal Control and/or Quality Control procedures. Most recent annual report. Latest 10-K and 10-Q reports filed with the SEC, if a public company. Target Market Client Profile. I. GENERAL INFORMATION 1. Name of Applicant: 2. Address of Applicant's Principal office: City State Zip 3. Name(s) and Location(s) of all branch offices: 4. Applicant's Web address: 5. Year Applicant was established: 6. Applicant is: Individual Partnership Corporation Other, please describe: 7. Is Applicant publicly traded? If yes, ticker symbol: If no, does applicant plan an Initial Public Offering within the next 12 months? 04/06 Page 1

2 8. Number of professionals employed at Applicant Firm: Clerical Staff: 9. During the past five (5) years: (a) Has the name of the Applicant Firm been changed? If yes, please explain: Yes No (b) Has any other business been acquired, merged or consolidated with the Applicant Firm? Yes No If yes, please provide details: 10. Is the Applicant Firm: (a) Controlled, owned, affiliated or associated with any other firm, corporation or company? Yes No If yes, please explain: (b) Providing any services to such business enterprises? If yes, please explain: Yes No 11. Name and location of all subsidiaries or affiliates for which coverage is desired: 12. Please give the names of any professional organizations or associations of which the Applicant Firm or its principals are members: 04/06 Page 2

3 II. SERVICES PROVIDED 13. Please provide a description of services offered by the Applicant: If Applicant Firm s services can be classified into any of the following categories please complete the appropriate Supplemental Application: Consultants Third Party Administrators Title Agents, Abstractors and Escrow Agents 14. Please describe only the services offered by the Applicant Firm for which coverage is desired and the percentage of total revenue: SERVICE % OF REVENUE % % % % III. APPLICANT S PROFILE 15. Complete with Applicant Firm's gross revenues: Next Year (Projected) Year US and Canada Number of International Clients $ $ Current Year $ $ Prior Year $ $ 2 Years Prior $ $ Number of Clients 04/06 Page 3

4 16. Indicate the percentage of the Applicant Firm s gross revenues that are derived from services provided to the following industries: Industry % Revenues Industry % Revenues Computer Related Financial Health/Medical Business Services Manufacturing Transportation/Utilities Education Games/Entertainment/Gambling Communications Legal Government Agricultural/Mining Scientific/Engineering Construction/Real Estate Wholesale/Retail Trade Consumer/Home Products Power & Utility Industries Pollution/Environmental Security and/or Privacy Fire, Security or other emergency Aerospace/Defense Other (please describe) TOTAL 100 % 17. List Applicant Firm s five (5) largest clients, a description of the services performed and the revenues received/anticipated for the last, current and next years: Name of Client Description Of Services Last Year Current Year Next Year (Projected) 18. (a) Describe the Applicant Firm's client selection process: (b) Does the Applicant Firm perform credit checks on all clients? Yes No (c) Is management's approval required for all new clients? Yes No (d) Does the Applicant Firm maintain a system to avoid conflicts of interest? Yes No 04/06 Page 4

5 IV. CONTRACTS AND LICENSING AGREEMENTS No 19. Does Applicant Firm use standard written contracts or agreements with every client? Yes If not, please set forth how often (% or #) and under what circumstances a standard written contract is NOT used: 20. Do the Applicant Firm's standard, written contracts contain: (a) Hold harmless or indemnity agreements injurious to applicant? Yes No (b) Hold harmless or indemnity agreements injurious to client? Yes No (c) Guarantees or warranties? Yes No (d) A specific description of the services applicant will provide to client? Yes No (e) Clauses defining the responsibilities of each party? Yes No (f) Clauses limiting the liability of the applicant? Yes No (g) A "force majeure" limitation clause? Yes No 21. Has the standard, written contract referenced above, been reviewed and approved by legal counsel? Yes No Name of Legal Counsel 22. When a non-standard contract is used, or when deviations to the standard contract are made, are such contracts or deviations reviewed and approved by legal counsel? Yes No If not, who has the authority to make changes? 23. Are all mid-term changes or modifications to a contract or service agreement made in writing? Yes No 24. Does legal counsel review and approve brochures, advertising or other similar literature describing Applicant s products/services? Yes No V. SUBCONTRACTORS 25. Does the Applicant Firm use subcontractors? Yes No (a) Services Subcontracted: Percentage of Total Revenue Subcontracted: % % % % (b) Do all independent contractors enter into a written agreement with Applicant Firm? Yes No (c) Does Applicant Firm require subcontractors to carry their own errors & omissions insurance? Yes No 04/06 Page 5

6 26. Describe the experience/qualification requirements for independent contractors or vendors: 27. Describe how Applicant Firm monitors and manages the quality of services performed by its independent contractors or vendors. VI. QUALITY CONTROLS/ RISK MANAGEMENT 28. Does the Applicant Firm have a disaster recovery plan? Yes No 29. Have any of the Applicant Firm s products or services been certified by a professional certification organization or industry association? Yes No If yes, please identify those products and services and the certifying association/organization: 30. Does the Applicant Firm have any certification and/or training requirements for their professional employees? Yes No If yes, please describe requirements, and identify the percent of employees that currently meet those requirements: 31. Does Applicant Firm have a document/contract retention plan? Yes No 32. Does Applicant Firm have formal customer complaint resolution procedures? Yes No If written, are they attached? Yes No If not written, please describe: 33. Does the Applicant Firm offer customer support services? Yes No 04/06 Page 6

7 34. Describe Applicant Firm s procedures for resolving disputes with clients/customers over fees or charges, should they arise: 35. Does the Applicant Firm have a formalized training program for newly hired professional employees? Yes No If yes, please decsribe: VII. HISTORICAL INFORMATION 36. Within the past three years, has the Applicant experienced any project delays or past due contract issues with any customer? Yes No 37. Within the last three years, have any of the Applicant s customers requested refund of their payment because of issues with Applicant s services? Yes No 38. Within the past three years, have any of the Applicant s customers withheld payments due to contract disputes? Yes No 39. Within the past three years, has Applicant sued any customers for non-payment of fees? Yes No 40. Describe the types of negligent acts, incidents, circumstances or exposures which the Applicant Firm believes could result in a professional liability or errors and omissions Claim or expose the Applicant Firm to a professional liability or errors and omissions claim: 41. Have any lawsuits or Claims been made against the Applicant Firm, its predecessors, subsidiaries, partners, officers, or employees during the past five (5) years? Yes No** **IF YES, ATTACH THE DATE AND A DESCRIPTION OF CLAIM(S), AS WELL AS CURRENT LOSS INFORMATION AND CLAIM STATUS. 04/06 Page 7

8 42. Have any actions have been taken to minimize the chance of a similar Claim? Yes No 43. Has the Applicant Firm or any of its principals, partners officers or directors been the subject of any disciplinary action by any governmental body or professional association within the last five (5) years? Yes No 44. Is Applicant Firm or its partners, officers, employees or subsidiaries aware of any actual or alleged errors, omissions, offenses or circumstances which may reasonably be expected to result in a Claim being made against the Applicant Firm or any proposed insured person or entity? Yes No If yes, please explain: 45. List any similar insurance carried during the past five (5) years. If none, check here: NONE Policy Period Insurance Company Claims Made Coverage Limit Per Claim /Aggregate Deductible Premium Retroactive Date 46. Has any application for similar insurance, made on behalf of the Applicant Firm or any of its predecessors in business, been declined or has any such insurance ever been rescinded, canceled or been refused renewal? Yes No If yes, please explain: 47. Coverage requested: Limit: $1,000,000 $5,000,000 $10,000,000 Other: Deductible: each claim ($10,000 minimum) THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY OR INSURE ANY SERVICES. HOWEVER, IT IS AGREED THAT SHOULD A POLICY BE ISSUED, THIS APPLICATION WILL BE ATTACHED TO AND MADE A PART OF THE POLICY. NOTICE: THE LIMIT OF LIABILITY IN THE POLICY, IF ISSUED, MAY BE REDUCED OR COMPLETELY EXHAUSTED BY CLAIM EXPENSES. IN SUCH EVENT, THE COMPANY SHALL NOT BE LIABLE FOR ANY JUDGMENT, SETTLEMENT OR CLAIM EXPENSES WHICH ARE IN EXCESS OF THE LIMITS OF LIABILITY STATED ON THE DECLARATIONS PAGE OF POLICY. 04/06 Page 8

9 THE SELF INSURED RETENTION IN THE POLICY, IF ISSUED, APPLIES TO CLAIM EXPENSES AS WELL AS TO DAMAGES. THE UNDERSIGNED(S) CERTIFIES THAT HE/SHE IS THE DULY AUTHORIZED REPRESENTATIVE(S) OF EACH PROPOSED INSURED WHICH SUBMITS THIS APPLICATION TO THE FOR A POLICY OF INSURANCE. THE STATEMENTS AND INFORMATION ABOVE AND ALL SCHEDULES AND DOCUMENTS SUBMITTED, OF WHICH THE UNDERWRITER RECEIVES NOTICE, ARE DEEMED PARTS OF THE APPLICATION (ALL OF WHICH SCHEDULES AND DOCUMENTS SHALL BE DEEMED ATTACHED TO THE POLICY AS IF PHYSICALLY ATTACHED THERETO), AND THE WORD "APPLICATION" REFERS TO ALL OF THE FOREGOING. EACH PROPOSED INSURED REPRESENTS THAT THE STATEMENTS SET FORTH IN THE APPLICATION ARE TRUE AND CORRECT, AND THAT REASONABLE EFFORTS HAVE BEEN MADE TO OBTAIN INFORMATION SUFFICIENT FOR ACCURATE COMPLETION OF THIS APPLICATION. IT IS FURTHER AGREED BY EACH PROPOSED INSURED THAT EACH POLICY OR RENEWAL THEREOF, IF ISSUED, IS ISSUED IN RELIANCE UPON THE TRUTH OF THE REPRESENTATIONS AND INFORMATION IN THE APPLICATION. EACH PROPOSED INSURED UNDERSTANDS AND AGREES THAT ANY INSURANCE POLICY ISSUED BY THE COMPANY SHALL BE SUBJECT TO RESCISSION IF THIS APPLICATION CONTAINS ANY MISREPRESENTATIONS OR OMISSIONS MATERIAL TO THE ACCEPTANCE OF THE RISK BY THE COMPANY. IF THE INFORMATION SUPPLIED ON THIS APPLICATION OR ATTACHMENTS THERETO CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE INCEPTION DATE OF THE POLICY, THE APPLICANT WILL IMMEDIATELY NOTIFY THE COMPANY OF SUCH CHANGES. SIGNED BY AUTHORIZED OFFICER, PARTNER OR PRINCIPAL DATE PRINT OR TYPE NAME & TITLE PHONE NUMBER If you want to learn more about the compensation Zurich pays agents and brokers visit: or call the following toll-free number: (866) This Notice is provided on behalf of Zurich American Insurance Company and its underwriting subsidiaries. 04/06 Page 9